Apgar Score: Things You Might Not Know About This Routine Test

Adjusting to the world outside the womb is no easy task for a newborn. Although babies do practice breathing in utero, baby is dependent on mom’s oxygen during pregnancy. But once baby is delivered, it’s up to them to breathe all on their own. And sometimes routine newborn procedures help babies make that very important transition. To support babies in those precious first few moments of life, many doctors and midwives use the tool of the Apgar score.

In this post we’ll cover everything you need to know about the Apgar test, including:

What the Apgar test is

The history of the Apgar test

What APGAR stands for

Plus, how the Apgar test is scored and what that score means for your baby

What is the Apgar Score?

Developed by Dr. Virginia Apgar in 1952, the Apgar test, also known as Newborn scoring and Delivery – Apgar, is an assessment tool delivery team members use to gauge how well a baby fared during delivery, and how well they’re adjusting to life after delivery.

Interestingly, an Apgar score doesn’t assess baby’s overall wellbeing. Instead, it gives us a clue into how well babies are breathing on their own and how well their heart is pumping oxygenated blood. It also helps the medical team determine if babies needs any medical interventions to improve breathing.

Virginia Apgar Was a Total Rockstar!

Virginia Apgar was more than just the woman who created the Apgar score. She was a pioneer in her field and an all-around awesome woman. Here’s just a sampling of what she’s known for:

She was one of only nine women in her med school class of 90 students at Columbia University’s prestigious College of Physicians and Surgeons.

She was an acclaimed anesthesiologist.

She was a maternal and neonatal health activist.

She served as chief of The National Foundation for Infantile Paralysis, now the March of Dimes.

She was the first woman to work as a full-time professor at Columbia University.

She was the first woman to head a division at Presbyterian Hospital.

She still had time to pursue a wide range of hobbies, including fly fishing, playing the violin, collecting stamps, and learning to pilot planes. (source, source)

Virginia Apgar’s Legacy

Despite all of that, what Virginia Apgar is most widely known for is the Apgar test, which she devised in 1952.

Displeased with the care neonates struggling to breathe were receiving, or rather not receiving after delivery, Dr. Apgar came up with a simple and effective way for medical professionals to accurately assess infants’ ability to breathe after delivery.

At the time, infants rarely received much attention after birth—most of the focus was on the health of moms. Since at least half of newborn deaths were related to hypoxia (inadequate oxygen levels), Dr. Apgar realized infant mortality rates could be reduced if more attention was given to an infant’s breathing immediately after birth. And she was right. The test is still used today, more than 65 years later, in every delivery room.

When Is the Apgar Test Given?

The test is usually given twice, once at the one-minute mark following birth and again at the five-minute mark.

Most babies won’t need to be tested again after the five-minute test. But if a baby’s Apgar score is low, baby may receive medical attention before being retested at the 10-, 15-, and 20-minute marks.

What does APGAR stand for?

Named after Dr. Virginia Apgar, it’s developer, the backronym APGAR was later used as mnemonic to help practitioners easily recall which physical signs to check. Each letter represents a different physical criteria a member of the medical team scores a baby on.

A = Appearance or skin color

For appearance or skin color, the infant’s care team is checking to see if the baby’s skin has a rosy pink tone. A pink skin tone usually indicates that the blood is well oxygenated and being efficiently pumped throughout the infant’s body. Because darker skinned babies have more melanin in their skin, a pink tone isn’t likely to show through. In this case, the medical team will assess general skin tone and color, and examine the soles of the feet, the palms of the hands, and the roof of the mouth.

A lack of color or blue coloring to baby’s skin could indicate that baby’s heart or lungs need assistance to function optimally.

P = Pulse or heart rate

For pulse or heart rate, a delivery team member will measure how many times the infant’s heart beats in a minute. Over 100 beats per minute is ideal. Anything below that may warrant an intervention.

G = Grimace or reflex irritability

This is a check on baby’s reflexes. To assess grimace criteria, a member of the care team stimulates the baby by suctioning his sinuses, stroking the bottom of his feet, or giving him a light pinch (definitely not my favorite option). They then observe baby’s facial expressions and reactions to see if he responds. They are looking for a grimace, cry, cough, and/or sneeze. A lack of response indicates baby may need medical intervention.

A = Activity

Activity is a measure of a baby’s muscle tone. The medical team gently extends baby’s limbs to check for movement and flexing arms and legs. If baby’s limbs resist being straightened, the muscle tone is strong. Limp limbs point to the need for an intervention.

R = Respiration or breathing

For respiration, the care team is gauging breathing effort. The team is looking for a hearty cry. Irregular gulps for air or a lack of breathing indicates baby needs immediate help.

How Does the Apgar Test Work?

One minute after baby is born, the doctor, nurse, midwife, or another member of the healthcare team evaluates baby in each category listed above.

For each part of the test, the healthcare team scores the baby on a scale of 0 to 2. An Apgar score of 2 means baby has shown the ideal sign for that part of the test.

Once the test is complete, the scores from all five factors are added together. Total scores range from 0 to 10, but 10s are incredibly rare because, hello!, baby just emerged from a rather traumatic event.

The scoring chart below will give you an idea of how points are assigned.

0 Points

1 Point

2 Points

Appearance

Pale or blue body

Pale or blue hands and feet, but pink tone to the rest of the body

Pink hands, feet, and body.

Pulse

No pulse

Less than 100 beats per minute

100 beats or more per minute

Grimace

No response

Twisted or scrunched facial expressions in response to stimulation

Crying, sneezing, and/ or coughing in addition to grimacing

Activity

Loose, limp limbs

Some bending of the limbs

Strong flexing of the limbs along with some resistance against attempts to straighten their arms or legs

Respiration

Not breathing

Irregular, slow

Strong cry, regular breaths

What is a Normal Apgar Score?

There are three Apgar score categories: reassuring, moderately abnormal, and low. A reassuring, or normal, Apgar score is seven or higher. Even if a baby gets a seven or higher at the one-minute mark, the test will be repeated at five minutes.

A baby with a low Apgar score at one minute, but a normal Apgar score at five minutes is showing signs that she’s adjusting well and any interventions given are having the intended effect.

A baby who falls in the low or moderately abnormal category after five minutes may require additional monitoring and medical interventions. When this happens, the apgar test may be repeated again every five minutes, up to 20 minutes.

Apgar Score

Definition/ Category

7-10

Reassuring

4-6

Moderately Abnormal

0-3

Low

Why a Perfect 10 Apgar Score Is So Rare

A “perfect” Apgar score of ten is rare, since most infants’ hands and feet will remain somewhat pale or blue for awhile after birth.

Because of this, most infants will get a 1 instead of 2 on the appearance criteria of the Apgar scorecard, resulting in a slightly lower score.

Though it will lower baby’s score, it’s usually perfectly normal for babies’ to have bluish extremities at first—their circulatory systems are immature and infants sometimes have difficulty staying warm. If the rest of their body is pink, there’s rarely anything to worry about.

What Are the Reasons for a Low Apgar Score?

Lower scores at the one-minute mark are very common, especially in high-risk pregnancies, c-section deliveries, premature babies, and complicated deliveries.

A low score on the Apgar scale doesn’t necessarily mean the baby is unhealthy or will have any health problems down the road. It simply lets the care team know a newborn is in need of a medical intervention.

Studies show altitude can affect Apgar score. It can take longer for an infant born at a higher altitude, where the thinner air means there’s less oxygen to breathe, to reach a normal blood oxygen level. The lower blood oxygen level, which usually reaches a normal level by five minutes, will leave baby’s extremities pale and blue longer, leading to a lower score even if the baby’s heart and lungs are functioning well.

What Interventions Are Given for a Low Apgar Score?

Some common interventions include:

Administering oxygen

Suctioning baby’s nose, mouth, and throat to remove fluid or mucus, and

What If Baby’s Apgar Score Doesn’t Improve?

If baby’s Apgar score is low at 5 minutes, the test will be repeated every 5 minutes for up to 20 minutes.

If baby’s score doesn’t improve, the healthcare team will continue to provide medical interventions to get baby the help they need.

How Important is the Apgar Score?

While there is an increased relative risk of serious complications for infants with low APGAR scores at the five minute mark, serious complications such as cerebral palsy are rare and can’t be predicted or diagnosed by a low Apgar score alone. (source)

The Apgar Score tells us only how well a baby is taking on the task of breathing outside of the womb. It is a tool for medical professionals to decide whether baby might benefit from additional medical care. Apgar score isn’t an indicator of overall health and doesn’t predict future health, intelligence, or development.

It’s also important to note that if a baby is in need of immediate medical assistance after delivery, a medical team won’t wait to intervene just because they haven’t done the Apgar test.

How About You?

What was your baby’s Apgar score immediately following birth? Did it improve by the 5-minute mark?